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SAN JOAQUIN Cr�,Y PUBLIC HEALTH SERVICES/ENVIRONMENTAL HEA�./IIVISION <br /> I. UG5T WORKSHEET FOR SITE CLOSURE EVALUATION DATE 3—/ -• ' <br /> NAME OF FACILITY O SWEEPS CODE <br /> ADDRESS O t S TANK ID 9 - /QS -02'_ p.3 <br /> TANK SIZE FUEL TYPE UL Qj <br /> !I. GENERAL SITE HISTORY <br /> iIs permit current? Yes HI I <br /> Permit 9 S/G. 0 JDc5on Facility Status Code Doc.Scil/GW Cont Yes No <br /> Number of Tanks at facility Age of Tanks(if available) Type of Tank Steell IFbrgLl ISngII Dual <br /> .:. TANK HISTORY <br /> vas Tank tested? Yes Na I V1Failed precision test ? Yes No If yes, give date" <br /> .as a repair made to the tank system? Yes No 1 6�If yes, what was repaired? <br /> ivas repair done underinspection? Yes NoWere soit samples analyzed? Yes No BTXE TPH-G TPH-D Pb/ED8 <br /> ;Type of failure/discharge catastrophic long-term Leakage overfill unknown other: <br /> IV. REMOVAL HISTORY (ATTACH INSPECTION REPORT FOR SITE DETAILS/COLLECT DATA FOR LEACHING POTENTIAL ANALYSIS) <br /> Soil Samples Received Yes No Depth to Ground Water 30 Ref/Year ;VF L, q,3 Average Annual Precipitation A= 14 10-25 <br /> On•Site Wells) <br /> as No Number 8 Type Irr Dom Pub <br /> S Score S Score S Score <br /> Distance to Well(s) from Tank ft; ft; ft C 10 pts C 9 pts C 5 pts <br /> 0 if 0 if 0 if <br /> R condition R condition R condition <br /> 'V. Site Feature . Leaching Potential Analysis is met E is met E is met <br /> Minimum Depth to groundwater from the Soil Sample (feet) >100 51-100 25-50\1 <br /> iFractures in subsurface (applies to foothills or mountain areas) None / Unknown Present <br /> Average Annual Precipitation (inches) xxxxxx <10 9- 10-25 xxxxxxx 26-40\2 <br /> (Man-Made conduits which increase vertical migration <br /> ,of leachate (i.e., septic systems, water wells, ponds) None Unknown Present <br /> (Unique site features: Recharge area, coarse soil, nearby weLLs. At least More than <br /> xxxxxx None one one <br /> COLUMN TOTALS>>>TOTAL POINTS s Z7 S - 3 Z <br /> Sample Result: (8 T X OR E) RANGE OF TOTAL POINTS 49 pts or more 41 - 48 pts 40 pts or less <br /> 8 T X I E B T % E <br /> MAXIMUM ALLOWABLE B-T-X-E LEVELS (PPM) 1 50 50 50 .3 .3 1. 1. NA\3 <br /> Sampl e,Result: GASOLINE 1000 100 10 <br /> �6yJ MAXIMUM ALLOWABLE TPH LEVELS (PPM) <br /> S TPH DIESEL 10,000 1000 70 <br /> FOOTNOTES: ***If documented soil and/or ground water contamination is present, do not complete the Leaching potential <br /> analysis. (i.e., site is currently on UGT Contamination List for soil or ground water.) <br /> \1 If depth is > 5 ft. and < 25 ft., score 0 points. If depth <=5 ft., do not use table. <br /> \2 If precipitation is > 40 inches, score 0 points. <br /> \3 Levels for BTXBE are not applicable at a TPH concentration of 10 ppm (gasoline) or 100 ppm (diesel). <br /> V1. STAFF RECOMMENDATION/CONCLUSION <br /> 1. Are BTX 8 E or TPN Concentrations > Allowable Levels *Yes No <br /> 2. Recommend Site Closure l Yes l Vi Nol If Yes, Refer to Site Mitigation for Evaluation <br /> VII. REVIEW EVALUATION - TO BE COMPLETED BY A ((SUPERVISOR/ NIOR <br /> CONCUR WITH STAFF RECOMMENDATION FOR CLOSURE YES NO REFERRED TO SITE MITIGATION FOR EVALUATION YES ` NO <br /> DATE REFERRED / / DATE CLOSURE LETTER MAILED <br /> NAME OF <br /> EVALUATOR <br /> EH 23 80 (UGTWKSHT)\5/90 <br />